How is Obamacare doing?

Yes, it is more popular, but how is it doing?:

Obamacare has continued to devastate the individual health insurance market:

  • In March of 2016, there were 20.2 million people covered in the individual health insurance market according to a hard count of state insurance department filings done by Mark Farrah and Associates.
  • In March of 2017 that count was down to 17.7 million.
  • In March of 2018 the count was 15.7 million–a 22% drop in two years.

This means 4.5 million people lost their individual health insurance in just two years.

Hardest hit are the 40% of middle class individual market consumers who are not eligible for a subsidy.

  • In March of 2016 there were 7,520,939 people covered in the off-exchange individual health insurance market where subsidies are not available.

  • In March of 2017 5,361,451 were covered.

  • In March of 2018 4,004,522 were covered–a 47% drop in two years.

And, the Obamacare subsidies paid to consumers are hardly sustainable.

According to the CBO, the average Medicaid outlay for a non-disabled adult is $4,230–a program that virtually has no premiums and co-pays. But because the risk pool is so bad and therefore expensive in the Obamacare exchanges, the average subsidy cost for taxpayers is $6,300–and that doesn’t include what the consumer pays in premiums and out-of-pocket expenses for Obamacare coverage.

Why has the Obamacare individual market melted-down in these last two years? Because its premiums and deductibles are sky high–for all but the lowest income participants.

In Northern Virginia, for example, the cheapest 2019 Obamacare individual market Silver plan for a family of four (mom and dad age-40) making a subsidy eligible $65,000 a year costs $4,514. That plan has a $6,500 deductible meaning the family would have to spend $11,014 on eligible health care costs before collecting other than nominal first dollar benefits.

That same family, but making too much for a subsidy, as 40% of families do, and a typical family in the affluent Virginia 10th, would have to spend $19,484 in premiums plus a $6,500 deductible, for a total of $25,984 in eligible costs before they would collect any meaningful benefits.

That is from Robert Laszewski, with additional interesting points at the link.  Do see my earlier post on what does and does not make sense in Obamacare — the risk pool for the individual market simply isn’t big or robust enough.

Comments

What is your evidence that Obamacare is responsible for devastating the individual market?

More than that, why would anyone think that America's individual health insurance market is something that needs to be retained?

Which has nothing to do with any single payer idea, by the way. Germany basically has no individual health insurance market (not on anything resembling an American framework or scale, that is), and yet manages to have a health care system with comparable results for a third less in cost.

And interestingly, though Germany does not have really have any individual health insurance market, it does have a private health care system, where anyone insured through the Krankenkassen (including the ones that would be considered 'individual' insurance providers) can go to basically any doctor/dentist in the country by handing over their health insurance card.

' the Obamacare subsidies paid to consumers are hardly sustainable'

Nothing in the current American health care system seems sustainable. In contrast, the German system Krankenkassen are currently looking at a surplus of around 30 billion euros.

Sounds like you are saying that, while Germany doesn't have a market, it, instead, has a market.

Depends on how one defines market, doesn't it? German doctors and hospitals are most definitely profit oriented, as are the German health care funds, On the other hand, the idea that a company like Aetna alone should make 27 billion dollars in profit to be distributed to shareholders is considered more or less insane (do note that Aetna's profit alone is essentially equal to the amount that the German Krankenkassen have collected over their current costs) - the 'Überschuss'of the Krankenkassen will be likely used to reduce the cost of health insurance in the future, for example.

The American system is hopelessly screwed up, even when compared to a system that is not in any way single payer, much less socialist. Private health insurance, at least when looked at using the American model that leads to excessive administrative overhead costs without providing any benefits to the insured, is not something worth keeping.

Unless one is an Aetna shareholder.

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than all your family members needs.

It's a miracle and it is all free!!!!

There IS a free lunch after all!!!!

No; his point may be that the American "system" is so abysmal because it gets neither the command-and-control advantages of a nationalised system, nor the competition, co-operation, value, and innovation of a free-market system.

Still, I suppose your key decision-makers are so rich, or so privileged (using that word in an accurate sense), that it isn't going to be improved unless as a response to some future economic calamity.

In which directions you should improve it I have no idea, though in your shoes I'd look more to Singapore than to the NHS in Britain. I'd certainly look at the Krauts, Frogs, Aussies, and so on.

That so heavily socialist a society as the USA can still frighten itself by crying "socialized" is amusing, in a wintry smile sort of way.

The American system is where people from other countries come to get health care. The American system can get you a triple bypass within a few hours where as the waiting period in most socialized health care countries is 24 months. The American health care system has more CT and MRI equipment available to the public than the rest of the world combined. Yeah, that's abysmal... DUH!

I recent that remark!

'The American system is where people from other countries come to get health care. '

You can keep telling yourself that, but it is not true. Or perhaps you are unfamiliar with how Heidelberg is fully able to complete for the customers you think you only go to the U.S.

I did not use the word "only". Many Canadians come to the U.S. for serious health care, not the flu or broken arms, but for needed heart bypass operations where the waiting period is extended if they are over the age of 60 or so. Many Canadians do not and take their chances and wait. Most Canadians who like to go "South" for the winter purchase insurance that will allow them to get healthcare in the U.S. while they are here. When I go visit relatives in Canada I do not purchase extra health care insurance and in the event I were to need non-emergency care in Canada I would find it easier to drive back to the U.S. rather than wait.

But you are now comparing apples to oranges - you don't purchase extra health care insurance for travel to Canada but then cite non-emergency issues as the reason why. You do tho' make the proper assessment of wait times in Canada as the biggest problem with our 'outta' this world/free' healthcare. Here in Canada if you are diagnosed with a serious problem like bypass surgery, it's as if the Gov't wants to wait & see if doing nothing will improve the condition.
But that idea only works well if you're a funeral operator. Nobody who is on a critical care/surgery wait list in Canada raves about our national health service. And many people requiring hip/knee joint replacement surgery often wait 2 - 3 YEARS in constant pain - after working & paying into the healthcare system for their entire working careers.

There maybe healthcare systems worth copying but Canada's needs serious improvement (bureaucratic waste) before you do...….

Not quite what I said. I don't purchase health insurance to go to Canada because "unless" it is an emergency I will go back to the states and IF it is an emergency I will have to pay cash and file a claim with my own insurance company.

I am waiting for a one size fits all Europlan. Some states here explored socialized plans for all. None yet. HSAs are the way to go here with catastrophic care and other options. Since the ACA, my selection of plans at work have dropped to two with HMO or EPO options.
I was able to keep my doctor through my plan and pay 20% of the premium. I don't trust any national government plan to deliver efficient health care. That's why Trump allowed veterans other options.

Where's the money for the HSA supposed to come from? A large fraction of the population cannot even manage to save 500$ for an emergency. Should we require that from employers? Probably not a good idea- healthcare needs to be less tied to jobs not more.
Why can't we just look at something that works for other advanced nations and go with a version of that?

The biggest problem I have with HSA's right now is that the employer changes plans so often, you've got to file paperwork to roll over you HSA's every time or end up with a bunch of little accounts everywhere.

Well you are a dick.

The BIG BIG BIG problem with obamacare, unlike free lunch Trump's tax cuts, is obamacare IN NOT FREE.

Trump's and the GOP tax cut is pure free lunch. Lower taxes plus much more spending, the opposite of Democrat party tax and spend while reducing debut load.

Since Reagan made free lunch economics the rule, tax cuts plus spending hikes are free as long as the GOP stays in power. Once out of power, the GOP demands democrats pay off their debt.

Bill Clinton fell for that. Obama learned from that to never fix the GOP problems, but simply pay for Democrat spending.

We shall see if the GOP will crash the economy trying to prove 99% of those over 67 have $3-5 million in savings so Social Security and Medicare can be eliminated and the 15% flat tax on wages can be dedicated to paying off GOP tax cut debt.

The non-partisan nature of your post makes it all the more credible.

Problem with Mulp's theory is that the Federal budget was balanced 10 years after Reagan's tax cuts and neither the Republicans or Democrats could stand it. They needed more spending to buy votes, such as Medicare Part D. Politicians love to spend other peoples' money.

Yeah those damn free lunch Republicans allowing taxpayers to keep some of their own money. Don't those bastards know that money is needed to give the indolent left free stuff? Where are our Obama phones??? We need more free stuff. Give us more free stuff or we won't vote Democrat.

Is it possible some of the people cited as having lost their individual plans actually moved to jobs with a health insurance benefit? Unemployment is quite low.

Sure -- but it may be that some of them did it only under duress (they'd prefer to be self-employed but can no longer afford it).

I am one of the people that moved out of the individual market. It was because I got a better job that had better health benefits.

I don't know how many more there are like me -- I am just saying that I prefer my new situation so it wasn't under duress.

Somewhat disingenuous using the Silver Plan. Thanks to Little Marco, the ACA law requires insurance companies to offer Silver with Cost Sharing, but Narco has made sure those cost sharing payments don't get paid. In retaliation, the insurance companies price their Silver plans high enough that they make up for the unpaid cost sharing payments. This has the unintended consequence of costing taxpayers more, as subsidies are based off of the second lowest priced Silver plan. Anyway...

Good news! Our hypothetical family (47, 45, 16, 12) in Frederick Co. VA can get a Gold plan for $278.93 a month and a family total (all 4) deductible of $4050 for the year.

If you have signed up for employer provided insurance this year I think this is pretty comparable with what we are seeing in that market for family coverage.

Wow, $278.93/mo is surprising. 48 y/o male here. Lowest cost Bronze w/ $7900 deductible is $479/mo for me on individual policy here in FL.

No subsidy, right? The family in question qualifies for a subsidy.

Frederick County is Winchester, not NoVA, but no chance they can get a gold plan for under $3,500/yr. Cheapest plan has to be at least $15k.

The author quoted said 10th District. I went online and got that quote for a zip code in the 10th district.

Cheapest gold plan in central VA for a family is $25k + $3k deductible

And that's for a crappy HMO, you pay $25k and still don't get to keep your doctor.

https://i.imgur.com/Q2tiLzk.png

In fact, there are no non-HMO individual plans available on central VA exchange.

Wow @Moo Cow - really? I tried, when I was in Northern Virginia a couple of years ago, to get a Bronze health care via the Obama exchange and the cheapest plan for a single UNEMPLOYED person with NO dependents, me, was about $1000 a month as I recall, with a high deductible of about $5k or so. However, I did qualify for free sterilization under some Virginia state run healthcare program (Google "three generations of imbeciles are enough", Buck v. Bell, 274 U.S. 200 (1927)).

Bonus trivia: my 1% family self-insures for nearly everything, except fire insurance and auto-insurance, and for the latter, when we have a fender bender we don't report it so our premiums won't go up.

Next year a 40 yo man in Fairfax County has 17vplans to choose from. The cheapest Bronze is $403 a month. With subsidy, $88 a month.

@Moo cow - thanks! OMG! I just found out that starting in 2019, in the state of Virginia, a new law was passed to allow adults under age 65 with no visible income and with no kids (that's me, as of the moment, hope to change that) to qualify for Medicaid? LOL! So I applied with my Obamacare account and was accepted, with some social worker to contact me said the pdf form. Free government cheese!! I bet the Medicare accepting doctors are incompetent but as of the moment I have no health problems so that's not an issue. That's a change from 2017 when there was an age requirement for childless adults of 65 yrs old. Bye Moo cow, thanks for the advice, I would not have even bothered to look if it wasn't for this thread. What a joke Obamacare is... good for a few laughs.

Health Cate is 17% of GDP but nobody wants to spend 17% of their income on it.

If you have a multi car collision where the other driver is cited your premiums should not go up. Many states even have regs to that effect. And if you are cited your premiums will go up whether you make a claim or not

You would almost think it unpopular. We have to be careful what we call Obamacare after it has been savaged by Republicans.

I hope everyone really concerned with cost goes with an HMO. Is irrational to prefer "your doctor."

Is very human, and very common, but irrational.

The amount of time my friends and relations spend on doctors' visits is irrational, when I observe that nobody is ever "cured" of anything; how frequently - especially among my women friends - vaguely-defined and symptom-less health "problems" are uncovered; and medications or treatments or suggested diets for the latter often beget iatrogenic effects.

I know, I know. I'm the irrational one. My husband says my attitude to doctoring is benighted and primitive.

And the truth is I love my doctor. He's Persian with lovely old-world manners. He took one of my organs and I didn't feel a thing. I see him in the neighborhood occasionally. But I have not seen him in a professional setting in over ten years. He murmurs something about how I never come in for an exam, but manages to suggest he thinks it's just fine, not to go to the doctor when one doesn't feel ill.

Excellent.

That would be correct if everything about that statement were not wrong.

Cost goes down when you maintain the same doctor. When you doc hop you almost always end up with duplicate care. Labs and imaging don't always hop with you and they get repeated all too often. Medication records also can be troublesome so you end up getting extra prescriptions. Over the longer term doctors get a better understanding of what a patient means when she says "my side hurts". For some patients you know that this means they have any nociceptive sensation in their sides at all and you opt for conservative management. For other patients you know the only time they have admitted to having pain was childbirth and you decide to get them an abominable X-ray because the odds that this is a stone or pyelonephritis is really high.

Then there are the signs that require you to know the patient. Is the patient having trouble finding the right words? Is that the first sign of a stroke and we should get a rapid CT or is this baseline for someone who has had subclinical memory issues for years?

When I see patients I have treated many times before I know instantly that my threshold for ordering tests will be readjusted.

More importantly a good doctor learns how to help patients be compliant with medical treatment. Is this a patient I can give a complex dosing schedule that will best manage their condition? Great let's do that for maximum benefit. Is this a patient that cannot? Well we need to look at depot injections maybe that will have worse side effect profiles, but at least prevent frank psychosis.

But can't all this just be in the chart? No. It is utterly impossible for two strangers to use words and terms in the exact same meaning. Even if we could get it all into the chart, your doc needs to then spend time reading it and be able to recall it during the visit as appropriate. Humans are social creatures and repeated social interactions are vastly better at building and maintaining this sort of social memory.

Healthy/young, high functioning, or rich, if you can hit two of three of those sure go with with the high churn, narrow network option. If you are like the majority of patients high churn is expected to shave at least a year off your life.

The number of times I have seen patients swap docs and the new docs miss something key (e.g. drug allergies that the patient forgot about, "normal" PSA in prostatectomy patients, vaginal bleeding post-hysterectomy) is reasonably high. Some of them cut the patient's life expectancy in half.

The only reason to nickel and dime with doc hopping is if you don't care about long term costs. Unfortunately this describes most insurance companies. For the patient whose time horizon is till the end of life, doc hopping is generally a pretty risky bet.

+1
I am always amazed at the number of people who think practice of medicine is like typing in a list of symptoms and out comes the same diagnosis with zero allowance for "local knowledge" of the individual patient. No wonder big government types love huge national one size fits all solutions (for everybody else.)

Thank you!

Your post is worth more than all the others combined!

Auto-correct can be brutal but funny: "... abominable x-rays ...".

Priceless!

My HMO let's you pick a doctor of record, though much trust is obviously placed in institutional knowledge, including computerized patient management.

"Sure" is one of those commenters that sounds smart and expert, until you realize he crosses freely into areas he does not know with complete confidence.

As in HMO as "doc hopping."

Yep, a HMO like Kaiser Permanente penalizes 'doctor hopping' in a way that is impossible to ignore.

Funny, I respond to a post explicitly mocking the idea of sticking with "your doctor" and somehow talking about doc hopping is verbotten.

Regardless, the whole point of the marketplace competition is to force buyers to swap plans to whatever is cheapest that year. Plans in turn can either price to be cheap (narrow networks, no expensive hospitals) or try to retain members they previously signed when they were cheap.

The "narrow network" option I reference is particularly prone to doc hopping troubles. The whole business model was pioneered by Centene. You sign on the docs who will take the lowest reimbursements and should they become too expensive in their reimbursement demands, you dump the docs and take somebody else.

As a business model they make decent money. As a patient it is frustating as hell when you sign up with young docs building a practice only to have to swap care for your chronic condition every couple of years.

Worse the model just is not scaleable. There are only so many cheap docs to go around and if reimbursement rates are too low for the hassle, docs will simply retire early.

Kaiser, of course, occupies the complete opposite niche. They do a lot of fun stuff to cherry pick patients (including illegal patient dumping a decade ago). They have obnoxious charges and hoard massive amounts of cash. Shockingly this too is not a sustainable model. They, at least, pay the docs well and do not have churn, but no Kaiser isn't encouraging you to stick with your doc for fun, they are doing it to weed out hypochondriacs and other expensive patients.

The truth is I have patients who have had to find 3 primary care docs in 3 years. Year one they signed on with a narrow network silver plan, ditched the old doc and found a new one. The next year that plan drastically raised premiums (it was spectacularly unprofitable that year), and that meant a new doc. The next year their new-new doc's practice decided that they did not like the price-volume tradeoff and the new narrow network decided to send their patients elsewhere.

Frankly, I find it hilarious that people talk about Kaiser in the same breath as Centene and company. One is clearly a high end outlier and the others are closer to marketplace standard.

This can be problem with group insurance too. It's common for many employers these days to switch to cheaper plans every year or two, which can force employees to switch providers too.

Obamacare, a disastrous program that benefits only the poorest of the poor, has a constituency now and can't be killed, not even by Ahab. We are stuck with it.

Those people in the caravans will all be on Obamacare and we will pay for it in taxes, reduced services, or a bloated deficit.

You can have a welfare state or open borders but not both.

Someone said that.

MAGA

From 2003 to 2011 I bought a buchcare plan with $5000 deductible that started at $450 a month and rose to $950 when obamacare required 80% of premiums go to medical care and the premium dropped back to $850 and then resumed rising, all before any obamacare exchange policies were offered. Then i got cheaper, to me, coverage.

Note, employer healthcare costs more than doubled while Bush was president, while costs were being shifted to employees, and employers were restricting providers, all at the direction of conservatives advising the GOP, and people like Mitt Romney and later John McCain on their presidential health care campaign promises.

Note John McCain wanted to take away every persons health care, especially employer provided insurance coverage. Then require everyone to buy individual polices.

@Moby's Dick - not true Captain Ahab. The Obamacare depends on zip code. For my tony Fairfax County, VA zip code, where the richest American live (Google this), including my top 1% family (min. net worth >= $10M), I, as an unemployed white middle aged man with no preexisting medical conditions, was quoted $1k a month in Bronze Plan premiums, with a high deductible. The point being it depends on where you live. If you can't stand Caravan people, move to Palm Springs, FL or CA, if you can afford it.

2019 - $403 a month Bronze no subsidy. If you report some famiky rental income of $30,000 a year and do a tax return, you would be eligible for a premium of $88 a month.

"Not true Captain Ahab"

Which statement is not true?

- Dick

If it benefits only "the poorest of the poor" that's not a very big constituency and they tend not to vote. I suggest you rethink your thesis.

Milton Friedman?

He said it too?

I thought I might be first. :(

Many of these people transitioned to other forms of insurance -- primarily employer sponsored insurance. The individual market is fluid, people go in and out depending on whether they have other options or not..

Yes. And many may have transitioned to Medicaid, where enrollment climbed from 72 million to 75 million in that same 2015-2018 time period. Looking at just the individual market's numbers isn't telling the whole story.

The costs of health insurance are high enough that for many people it may no longer be a financially smart decision to buy insurance. Paying $10,000 - $20,000 annually, with no benefit other than preventing a small risk of financial disaster in the event that your family has a major health issue, is probably not worth it for many.

Which is why many people are happy Trump and the Republicans eliminated the individual mandate.

Liberty!

No one "eliminated" the individual mandate. It was ruled unconstitutional.

In other words, it never should have been implemented in the first place, and its effects on the pool should never have been counted. Obamacare was less solvent than it was sold to be.

A corporation doesnt get to include profits from illegal side operations in its financial statements.

The individual mandate was upheld by the Supreme Court as a constitutional exercise of Congress's power to levy a tax in National Federation of Independent Business v. Sebelius, 567 U.S. 519 (2012). The Tax Cuts and Jobs Act of 2017 eliminated the tax penalty for failing to purchase insurance. The mandate itself has never been ruled unconstitutional by the Supreme Court, though there is a pending lower court case in which Republican state Attorneys General have made that argument.

Calling a fine a "tax" was fine example of pretzel-logic by Roberts. It's as nonsensical and openly politically motivated as the pretzel-logic in Wickard, and will probably have just as many long-term deleterious effects.

In a family, "disaster" is almost certain unless you eliminate family or engage in suicide.

But if you place a low value on life, suffering then death, or death than suffering, ie accident, cancer, stroke ending in death, or heart attack death leaving dependents high and dry, are apparently ok with you.

Getting medical care without insurance or hundreds of thousand in cash is really hard, other than while dying in the ER. If you can find one.

Oh please. I actually treat people who do this. You have 10 months of the year where you are at risk, otherwise it's open enrollment period and the "no-prexisting condition" clause means you can safely buy gold plated insurance at that time.

So now the question becomes when do you get care. Okay let's walk through your scenarios:

Accident, okay had an MVC not too long ago with a nice splenic lac. We had OR prepped before he arrived (when the paramedics have trouble controlling the bleeding and we have visibly growing abdominal distension we know its bad). He burnt through something like $100K in emergency surgery. Last I heard, he is going to declare chapter 13 and walk away burning maybe $25,000 in assets. Most accidents are either cheap (i.e. 99% of patients the worst possible outcome is bankruptcy. This is actually not that terrible for most people. Roughly 20% of adults have done it.

And the actual incidence of these risk is really low, particularly if your demographics are good. Cancer, for instance, will strike <1% of us any given year. MVCs are more likely, but still under 2% per year with <1% requiring treatment. Stroke, heart attack, and the rest are pretty unlikely to start with and basically unheard of in generally healthy adults until at least age 45.

As somebody who sees people "dying in the ER", you are simply incorrect. I have diagnosed literally every example this week. Zero of these patients will be unable to receive timely treatment without insurance.

Health insurance is asset protection. Obamacare has drastically warped incentives to the point where young healthy people are vastly better off (low assets, low odds of major healthcare costs) without unsubsidized insurance (excepting, of course, pregnancy).

This was, after all, the whole premise of Obamacare. Drop the costs for the near elderly (to get their buy in), raise the cost on the young (assuming them to be oblivious), mandate that everyone buy things from insurance companies (with a bunch of socialization of the downside risks and high profit potential) for their buy in, and have everything was out to net zero change (or I'm sorry, save $2,500 per year for everyone somehow). I mean sure there were some half-assed attempts to cut reimbursement rates, but I suspect those will all be offset by the growing monopoly power from the healthcare consolidation the ACA encouraged.

At the end of the day the young will only buy into ACA coverage if they are financially dumb, civic minded, or forced to at gunpoint.

This. Now the individual mandate is no longer in effect - AND the time limit on short term plans was repealed. Amazing that this reality hasn't been given more coverage, it's a huge deal. The ACA does not have legs to stand on, the adverse selection death spiral can only accelerate.

We will see how rational the market is. I'm amazed at how bad most people are at understanding these sorts of things, but when word of mouth gets around that you can get a catastrophic family plan for like $50 a month instead of $500.

Seriously, the premiums/terms of these non-ACA plans are wild compared to what we've been conditioned to expect. A family of 4 can get a catastrophic plan for $100 a month.. or for $300 a month (much less than the cost of ACA bronze) you can get a plan with $1000 max out of pocket.

Link to those plans please?

It has been some years since I had one, but back in my 20s post university career-gap I used this website:

https://www.agilehealthinsurance.com/health-benefit-insurance-quotes#compare

Sorry my bad, I linked to the indemnity plans not the actual insurance plans, this website needs an edit button:

https://www.agilehealthinsurance.com/short-term-health-insurance-quotes#compare

Thanks. So yes, this is very limited coverage. If you can thread the needle, good. No baby birthing. No ob/gyn. No drugs.

Most of these are limited to $250,000 or $500,000 max. Which is probably fine for probably 95% of cases.

Last I heard, he is going to declare chapter 13 and walk away burning maybe $25,000 in assets.

This is rational for lots of people. Even upper-middle class people can roll a lot of their wealth into their homestead and just declare BK if the waters get too deep.

A better than going bare is to take out a much less expensive, non-ACA compliant short-term policy. If disaster strikes, then it's time for an exchange policy during the next open enrollment period.

Obamacare reminds me of a big ole cat I got - I call him Big Barry. He likes to drop a big one in the litter box without burying it. By the time we process the chemical signals it's too late. No matter what we do the odor lingers for hours.

+1

Thread winner.

Laszewski's interesting points lead to one conclusion: put everyone in the same risk pool so the risks are spread across the healthy and the unhealthy, the young and the not so young. Well, that would be one solution but it's not Laszewski. First, he would add what he calls "flexibility": allow insurers to offer skimpy plans to attract more healthy insureds and thus improve the risk pool. It would improve the risk pool and everyone is better off except for those who buy the skimpy plan and get sick; the skimpy plan shifts much of the risk to the insured. Second, he would eliminate the mandate to purchase a plan and modify the mandate for insurers to cover preexisting conditions: anyone who does not buy a plan when first eligible would be subject to a six-month waiting period before preexisting conditions are covered. Again, his solution shifts much of the risk to the insureds. I don't doubt that Laszeski's solution would improve the risk pool and lower premiums, but it mostly ignores health insurance costs not covered by the skimpy plans and those attributable to preexisting conditions not covered. Who bears those costs? Hospitals in the first instance, but ultimately the unlucky bastards hounded by the hospitals to collect. Criticizing Obamacare is like criticizing politicians: we all do it but elect the morons anyway.

To add a little perspective, our health care system is stable and effective in comparison to China's: https://www.nytimes.com/2018/09/30/business/china-health-care-doctors.html

At the end of the day, if you assume people are rational (not quite true, granted), the premise of combining risk pools is unstable. Which insurer will a healthy person choose - one that pools them with aging diabetics, or the one that pools them with other healthy people?

The point of the individual mandate was to prevent that from even being an option. In that way it was socialized-healthcare lite. Curious to see if the ACA can sustain itself on sheer inertia in the face of economic truth..

Tyler, you should be ashamed by this biased and intellectually lazy post. Ashamed.
1) Why didn’t you highlight the article’s other main point? That voters like Obamacare for the security - not being denied coverage for a pre-existing condition.
2) Why no mention that the pools are expensive is because a key component of it - that everybody that doesn’t have insurance buys into it - was struck down? Or the numerous other attempts by the republicans to sabotage the system?
3) Why no speculation about other things that may have reduced the privately insured? Such as higher employment and more people switching to insurance through their jobs?
4) It is easy for you, a “libertarian” to bitch about Obamacare when you enjoy your tenured job and cushy benefits at a PUBLIC university. You have no clue what living in an actual libertarian world, with no consumer protections, is actually like.
5) Why is health care for everybody unsustainable? Poorer countries have afforded it for decades.
6) Obamacare was the free market system of health care you should have endorsed, albeit with some basic consumer protections. Why don’t you write specifically what you would improve or change or what system you would replace about it?
7) Why no acknowledgement of the people who would be dead without it?
Shame.

Very good post. I had experience a couple of years ago helping out some family members get Obamacare policies. At the time they were independent contractors, earning a decent salary, and did not have a full time employer who provided benefits. There are lots of young people in this position and they don't get subsidies.

The numbers in the paper are a little fishy as I don't see an accounting for those who dropped out of the Obamacare system because they moved on to full time jobs (the case with both my family members) or because the individual mandate was struck down. We are also seeing premiums going down this year and the markets appear to have stabilized.

1. Something for nothing is always popular.

2. The individual mandate was illegal. Removing it isnt "sabotage." Including an illegal element is "fraud."

3. He should have considered those things. But then Obamacare doesnt get credit for providing them with insurance. Employers do.

4. Sophistry. Ad hominem. They WORK for a living, and they get insurance as a benefit of their employment. This is entirely consistent with their beliefs. Maybe the people who dont have insurance ought to stop being useless to the economy.

5. For the same reason every other socialist program is unsustainable. Eventually you run out of other people's money. And it is theft. See 2 above.

6. They have written about it many times. Do your own research.

7. Why no acknowledgement of the people dead because of it? Shame. The blood of 100 million people and the tears of billions of oppressed people are on your socialist hands.

The assertion that the individual mandate was illegal is false. The individual mandate was upheld by the Supreme Court as a constitutional exercise of Congress's power to levy a tax in National Federation of Independent Business v. Sebelius, 567 U.S. 519 (2012).

The ACA is not something for nothing. One of the principle complaints is that the premiums are too high.

I have a couple family members in the individual pools as well. Before, and after Obamacare. Prices skyrocketed.

Re #4 - It is fair to say that any system lacking "consumer' protections is going to flat out suck. Scare quotes because under some arrangement the label or even concept of consumer may not apply.

So your addition of the political label libertarian world is meaningless. Moreover, you make that charge without any justification or caveat regarding what form of libertarianism you are referring to or even if that form is one your target would agree fits his understanding of the social form.

If the rest of your items are as hyperbolic as this was you're not really saying anything.

1) Because it makes the Obamacare structure worse. Your insurer was already unable to cancel your plan back in the day. But, thanks to the gutlessness and partisanship of Congress we have locked people into employer provided healthcare so it was a legitimate issue (rather than doing something sane like banning employer provided healthcare and allowing everyone to buy their plans pre-tax). Unfortunately, the way things were structured this "protection" directly undermines affordability as they have drastically aligned incentives for freeriding when you are young and buying in when you expect major costs (e.g. pregnancy and old age).
2) Because it was blindingly obvious. We allegedly cannot stop people from smoking pot, but somehow we are going to throw the not-quite-poor-enough people in jail for buying a product that is a net loss to their well being? The cost of enforcing the mandate with serious non-compliance was always going to be impractical. You might have made a go of it from general civic obligation, but then you would have had to have built broad based social support for the system rather than ramming it through after a Republican wins MA explicitly running to block it.
3) Because this would have happened regardless. Insurance rates go up when the economy improves. Quite likely the effect would be greater as fewer people would face some obnoxious effective marginal tax rates by taking better jobs and losing access to subsidies.
4) The majority of my patients are Medicaid. A huge minority are homeless. I also treat the jail prisoners. I know exactly how their world works. The plans on the exchange are abysmal for them. Want to get a primary care doc? Great I got a list dozens of patients long who come see me at ~$1000 a pop or (if they listen to me urgent care at ~$250) because nobody in primary care takes their "narrow network" plan and new patients. Worse when we actually do get them primary care, the network decides that the doc is too pricey and tells them "sucks to be you" and provides a useless list of new docs that it will only take twenty to forty hours to run through to find a doc. Oh, and you know how nice "narrow networks" are when you don't drive anywhere but rich metropolitan areas? Yeah, that's how the other half lives.
5) We are not willing to let people die. I have done healthcare overseas. I have done healthcare in the US. Over there they tend to ration everything except primary care by wait times. This directly leads to patients dying. We have treatments that add months or years to lives. They are willing to let patients die months or years sooner. We invest almost more than the rest of the world, combined, into healthcare research. Overseas they prefer freeriding and letting people die until we make treatments more cost efficient.
6) Ban employer's from deducting healthcare as business expense. Allow all Americans to purchase healthcare pretax however they like. Heck maybe just give Americans a $5000 per annum healthcare voucher and be done with it.
7) Because they don't exist. We did a nice natural experiment in OR. Getting health insurance moved the needle on mortality ~0%. Frankly, if anything I suspect that Obamacare's incentives towards mergers and vertical integration will result in enough disrupted care to actually kill people but that might take a decade to sort itself out.

The truth is all Obamacare did was change who paid for healthcare how. It did not lower the price. It did not inject new resources. We just had a major political fights to make a different set of people lose money (young and healthy) so a more favored group could keep it (old and sick).

If you want better healthcare (and I don't recommend that from the public purse), you have to dump in more resources or make it actually cheaper to provide care. It is $50,000 just to do a HIPAA compliance audit. Actually being compliant requires staggering wastes of time and money. Billing requires so much obnoxious paperwork (be it for the government or insurance regulations) that it is literally cost effective to pull RNs and MDs out of service to do nothing but improve billing paperwork.

Futzing around with if person A or person B pays more of the total cost of the insurance pool does precisely piss all to lower costs. Adding in a new org chart about who makes decisions is yet another idiotic cost sink. If there was money laying on the ground to provide actual healthcare why had NO ONE picked it up before Obamacare? Not CA. Not VT. Nowhere.

Frankly I suspect pretty much all of this mania about who pays for healthcare comes from an inability to do cross national comparisons correctly. But such is life. May as well keep rearranging the deck chairs after hitting the iceberg.

I have to dispute the "let people due' meme. Does any system ration emergency and critical care purely by wait time, as opposed to rational medical triage whereby people suffering life-threatening situations (who can likely be saved) are treated ahead of less serious cases? I very much doubt it.

What is the evidence that those people "lost" their insurance? Could they have gone to an employer plan in the rising economy? And what were the costs before Obamacare and how fast were they rising? I ran a business in Massachusetts from 1999 to 2015, and we had to raise employee contributions and lower benefits every two years to keep up with rising private insurance costs. After Romney-Care passed (which was the blueprint for Obamacare, and the result of numerous working groups with individuals, businesses, insurance companies and state government), our costs finally stabilized and we were able to offer employees more options, including the option of using the state Exchange.

It is very suspicious that this piece prefers numbers on the individual market over the traditional concern .. numbers uninsured.

This page shows US (and Montana) rates falling through 2016.

Seriously, Tyler?

http://www.mtpr.org/post/montanas-uninsured-rate-steady-medicaid-expansion-beneficial-new-studies-say

Obamacare is an individual market mechanism. It makes no sense to look at the unemployed rate or medicaid expansion

Here is data taken directly from the Consumer Expenditure Survey. The Affordable Care Act has driven very large increases in costs to average consumers for health insurance.

Funny how a law passed in 2010 can produce inflection starting in 2008.

There are obviously some Great Recession artifacts in there about household pay and household expenditure.

Probably are, but the graph shows the sharp increase in 2013, not 2008

Here is the evidence that the flipside of increasing health care costs is increasing health insurer profits. The health care money goes somewhere, and to a large extent, it is going to insurance companies.

https://www.axios.com/profits-are-booming-at-health-insurance-companies-1513302495-18f3710a-c0b4-4ce3-8b7f-894a755e6679.html

Obamacare "drives" increase health care costs the same way the government drives record bank profits. Obamacare is deregulation and crony corruption masquerading as a government takeover.

I can imagine if everyone were forced by law to own a car Ford and Chevy would be doing great as well. Also, the graphs are in dollars, not percentages. When you expand an industry with high fixed costs but 10%, most of that will be profits.

Well exactly. But what would be remarkable would be if politicians could convince people that the Ford/Chevy Mandated Purchase act was socialist

Mandated? Even for cars it sounds socialist.

>Obamacare has continued to devastate the individual health insurance market.... the Obamacare subsidies paid to consumers are hardly sustainable....

So, it's working exactly as designed, then.

Typical conversation about Obamacare ---

Observer: "Here is some more data that shows Obamacare is failing in exactly the way it was predicted to fail."

Obamacare defender: "No, those numbers are wrong. Obamacare is a huge success. Republicans are to blame for its failure (despite the fact that it's a huge success)."

Reformer: "We should at least allow alternatives, like short-term and association plans, to address Obamacare shortcomings and allow for innovation."

Obamacare defender: "Those alternatives are far inferior to Obamacare and always will be. We can't allow alternatives because they will siphon away money from Obamacare (despite being inferior). We have to protect Obamacare because it's working so well (despite being so fragile that it can't tolerate any competition)."

Actually, this seems to be the typical conversation about any government program: Obamacare, K-12 education, post office, mass transit, anything that could be outsourced to private contractors,...

Well, isn't the first attack more like "here is a datum I found that confirms my previous expectations?"

Obamacare isn't perfect, and it couldn't be, given the constraints on its passage.

But if the one big thing it wanted to achieve was a reduction in uninsured, it did that.

Forced labor camps reduce unemployment.

Providing insurance to some people who pay nothing for it at the expense of others, in terms of taxes, higher premiums, and lower quality, is a form of theft.

I don't praise Al Capone for providing social assistance to poor Italians.

Its called 'community rating'.

You're some kind of nut.

This guy gets it. +1. Start a blog, please.

In exchange for being allowed to continue their quasi-monopoly racket of fleecing captive customers (for record profits), insurance companies were required to cover preexisting conditions (cue tiny violins), which the insurance companies promptly priced-in through higher premiums and deductibles. As gravy, the program created a larger captive market of comparatively healthy customers through mandates and herded them onto the insurance companies' books.

The only thing Obamacare was designed to do is perpetuate the corrupt and inefficient private system, protecting it from its own excesses and failures - to protect it from true reform. And to that end, it is a huge success.

That this program gets labeled socialism by ignorant morons is among our age's most fascinating ironies.

Another level of dishonesty might be calling this Obamacare when it covers pre-existing conditions without universal mandate.

The individual mandate was illegal. You do not now should you have ever counted its effects when evaluating Obamacare.

The assertion that the individual mandate was illegal is false. The individual mandate was upheld by the Supreme Court as a constitutional exercise of Congress's power to levy a tax in National Federation of Independent Business v. Sebelius, 567 U.S. 519 (2012).

[Hackers stole income, immigration and tax data in Healthcare.gov breach, government confirms](https://techcrunch.com/2018/11/09/hackers-stole-income-immigration-and-tax-data-in-healthcare-gov-breach-government-confirms/)

A family of 4 making $65,000 -$11,014 would still be in the top 20% world wide, why would we try to subsidize those people?
The problem is we think it could be much cheaper and I agree it could be, so PPACA addresses the problem from the wrong end, and at the wrong level better addressed at state and local level.

"... to 20% world wide, why ...subsidize those people?"

Nobody lives "world wide", they live locally. In some locations the cost of living is so high that $65,000 for a family of four is not enough. In my dog-eared neighborhood a house for a family of four rents for $3600/mo. To earn $65,000 usually requires a long and dangerous commute that requires an excellent car + insurance + high fuel costs (carbon tax included) + high DMV fees + high state and local taxes + high HVAC costs.

Note I am referring to an actual family and house, not some theoretical case.

The only thing cheap around here is talk.

What city is that? I'm a YIMBY.

When I was a kid we lived in an apartment with my parents and 3 brothers and 1 sister. It was great because my cousins lived down stairs. It was not a big apartment is there nothing like that near you for less than $3,600/month?

I live in the woods very close to Silicon Valley. People are almost desperate for housing and live in tool sheds, converted chicken coops, trailers, RVs, tents, yurts, and vans. So, no, there isn't.

I guess if you can't get your local government to allow more building, you'll have to move. No reason to subsidize your living in such a strange place.

BTW in a NIMBY area a rise in Healthcare costs should lead to lower rents and a subsidy for healthcare, will partly be captured by homeowners through higher rents.

Not here. Demand is virtually unlimited.

Then your landlord should raise the rent, a lot, by like 10X what it is now.

My Republican Moral Minority position is that everyone should buy health insurance in open market, by the federal government should provide vouchers for minimum care for the poor.

So you don't get unintended consequences like a healthcare network being required to pay for any uninsured who walks in the door. That is on the public dime, but should be reclaimed from the rich-but-stubborn uninsured who refuse to pay. With penalty.

Who is pushing this bill? How many votes they got?

I'm up for a Singapore or even Switzerland hybrid. But there are no politicians even proposing such a thing.

The ACA is modeled on the Swiss and Dutch systems

Funny how the free market can make everything available efficiently except healthcare.

Why not get government out of healthcare altogether and allow people to buy/sell health insurance or medical care as they choose?

More amazing is that nobody is advocating for that on supposedly libertarian blog.

As an aside, the lefties were upset last week that a Nobel Prizewinner had to sell his Nobel Prize, for like a million, to pay for his Healthcare.

My Republican Moral Minority position is that the dude had a million, did not need subsidies.

No. The point was that even millionaires are not protected from getting bankrupted by health care costs. Despite it being a ridiculously expensive highly profitable system, it does not actually do much in terms of serving its putative customers.

Insurance is a rip-off to the healthy, it is also a rip-off to the sick.

Are you suggesting that his out-of-pocket costs were fully a million? If so, he had a million in net worth and was uninsured?

This does not seem like a problem government can really fix in a free Society.

I have no idea what his circumstances were. He is representative as a symbol of the dysfunction of our system.

I dont know your definition of the limitations in a hypothetical “free” society. Our society is a hybrid of free, managed, and corrupt. And in our society, there’s a lot that can be done.

No one should be "protected" from bankruptcy due to medical costs.

Health care consumes scarce resources that must be paid for. Those payments should come from the people who use them or they will be over allocated. People buy their own insurance as protection against such catastrophic losses. If they don't, they shouldn't be allowed to keep anything but the hospital scrubs on their backs.

But you are free to dig deeply into your own wallet to pay their costs.

Actually, insurance does not protect against catastrophic losses.

You have a major unfounded premise that health care is a scarce resource, like its a gemstone. The scarcity is in fact deliberately manufactured

Unless you reinstitute slavery, it's a scarce resource.

Sophist rubbish

The supply of everything from doctor to drugs to insurance companies is deliberately throttled

Maybe so, but it's still a scarce resource when not throttled.

Politics is the art of the possible. You're not going to convince hardly anyone of your social darwinist suggestion any more than you'd convince them to reserve police protection and the justice system for those who can pay for them. People en masse have decided that healthcare (which is not exactly "scarce") should be available to everyone. Best to deal with that fact and help find the best way to accomplish it.

Well Obamacare has sure worked for my wife. The poor thing. And now 3 times in less than 2 years. When the medical or surgical SHT really hits the fan, Obamacare does indeed come to the rescue.

No doubt some people win the insurance lottery.

I would guess it is those who get conventional treatments in large units, like a $50 to $100k procedure.

Their $20k premium plus $10k out of pocket put them net positive for that year.

And the insurance itself provides value in terms of access to the insurer’s negotiated discounts, instead of the provider’s ludicrous top line fees

No fun winning this lottery! Obamacare does get major discounts from providers. For my wife's trauma with pricing over $1.3M, her policy paid out around $300-350K.

Ugh no not much of a lottery

Obamacare has been a disaster for the self employed. In NYC a "silver" policy for two will cost about $20K annually with a large deductible. That is about 2X what the cost was pre-Obama. But even that comparison is misleading because the post Obamacare coverage is way less in terms of quality doctors and hospitals and doesn't factor in the deductible and the co-pays.

Our group policy costs that for a family of 4.

$5k first dollar deductible

We had an individual major medical policy before Obamacare. We were paying in the $14-17K range back then. And actually a higher deductible. We did have almost an unlimited network. But today we are more limited by what our small town has to offer, not Obamacare per se.

So in 16 there were 20M people buying insurance 'individually' and now it's about 15M. Glancing at https://www.statista.com/statistics/192356/number-of-full-time-employees-in-the-usa-since-1990/, though, it looks like full time workers alone went up by about 2M+.

How many people stopped buying individual health insurance because they got a full time job with benefits or their spouse did? I'm not seeing anything here that wouldn't be fixed by giving the subsidy more support and stopping the childish attempts by Trump to sabotage Obamacare because it's called Obamacare rather than Trumpcare.

Yes, the OP was bordering on a blatant troll

Most single-payer system are small countries without a lot of options and not concerned about service in the first place. Larger countries prefer options and like quick service. The only thing holding back efficient and affordable health care in the US is government regulation and coercion.

MR perhaps prefers universal health care. Countries with higher life expectancy than the U.S. in 2016 all had universal health care. The number of countries with a life expectancy higher than the U.S. has more than doubled since 1960. Cuba now has a higher life expectancy than the U.S.

This feels like a very weird Tyler post. I have a lot of criticisms of Obamacare and I know Tyler does too, but this seems to take as conclusions things not really known.

The U.S. Government can make health care work when it wants to. Dr. Ron Paul provided socialized health care to U.S. Airmen when he was a flight surgeon in the Air Force in the 1960's. His service gave him valuable training and experience which he put to good use in his private medical practice afterwards. He wasn't an incompetent physician when he wore an Air Force uniform and drew a government paycheck who mysteriously became competent when he wore civilian clothes later on and had to make his own living.

The American healthcare system is a disgrace.
Stop trying to be clever and just do what Europe does.

What does 'Europe' do? There are several different systems in Europe. Which one do you think we should do?

It's funny how people get to pick and choose what exactly "European" is. We should do healthcare like Germany, welfare like Sweden, school lunches like France, siestas like Spain, and drugs like Portugal.

Though not intentional, it sounds like a good case for federalism.

Why is the risk pool so bad? These are people who have higher than poverty income, hence are not too sick too work. They're also people who don't have group coverage through work, so the population probably skews a bit young. I can't see why this would be any worse than the average employer group population.

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